Table 5 Summary of recommendations for future diabetes prevention work

1. Implement a whole of systems approach to pre-diabetes care which honours the principles of Te Tiriti o Waitangi^a, and in addition to general practice care includes public health and social services measures. This should address the fundamental root causes of pre-diabetes and T2DM such as inequalities in SDOH, racism, food environments, and physical environments

2. Review funding systems, to ensure proactive, comprehensive equitable pre-diabetes care is incentivised and can be provided in a range of settings including general practice or community settings

 2.1 Appropriately fund pre-diabetes care in general practice and other organisations, with particular emphasis on resourcing services and different disciplines and skill sets for team-based interprofessional care. Specify the skill sets and agencies required to provide comprehensive culturally appropriate lifestyle interventions and how they should work collaboratively

3. Develop the evidence base for effective and sustainable lifestyle modification particularly in relation to high-risk populations. Such approaches may best be done through a whānau ora model [91] which is integrated into care pathways and guidelines

 3.1 Given the evidence, the fundamental importance of weight loss in diabetes prevention needs to be emphasised in diabetes prevention services; however, this must be done in a culturally tailored manner

  3.1.1 Implement evidence-based measures to support weight loss including use of dieticians, and culturally adapted community-led, [92] whānau/group or possible commercial programmes

 3.2 Partner with communities affected by high prevalence of T2DM (such as groups related to ethnicity, geographic region, socio-economic status, community or intergenerational patterns of diabetes) to develop and employ new models of diabetes prevention which are community/whānau focused, culturally congruent and target multigenerational patterns of diabetes

 3.3 Research the outcomes of current and new models of care

4. Refine national guidelines for pre-diabetes care

 4.1 Develop simple tools to risk stratify those with pre-diabetes, so that higher risk groups can be more intensively targeted, and resources used wisely

 4.2 Emphasise the importance of pre-diabetes care in management guidelines. Ensure the guidelines:

  4.2.1 include social deprivation in the list of risk factors for T2DM, so this is highlighted, and those experiencing deprivation are appropriately screened

 4.2.2 develop separate pre-diabetes treatment algorithms which:

  4.2.2.1 specify recommended treatment intensity, treatment escalation and frequency of monitoring which are linked to level of risk

  4.2.2.2 clarify when and in what groups metformin should be prescribed

  4.2.2.3 incorporate appropriate guidance for assessment and management of other risk factors or co-morbidities

  4.2.3 acknowledge that deprivation makes attending appointments and adopting evidence-based guidance more challenging and integrate into guidelines how this can be addressed